2.0 Analysis 2.1 Breakdown in Communication There was a breakdown in communication between the vessel's agents and the master of the YPAPADI. While en route, the master was advised by the agent that a pilot would board on arrival in Gasp and he was given the position of the pilot station. This information was never rescinded. When the sub-agency representative boarded at the pilot station, the master believed that he was the pilot he was expecting. To add to the complexity of the situation, the newcomer responded to the appellation Mr.Pilot without advising the master that he was not, indeed, a pilot. It is not customary for a ship master to ask a pilot for his credentials. The course and speed, a proxy for the vessel, were handed over to the pilot and the master was confident that the pilot knew the port and knew how to conduct the vessel to her berth. A perfunctory hand-over from master to pilot can lead to a breakdown in communication, but such hand-overs are not uncommon. A more professional hand-over would involve, inter alia, the master giving the pilot information on the vessel's handling characteristics, and the pilot outlining the proposed harbour passage. A more thorough hand-over would have alerted the master to the actual status of the person who had boarded at the pilot station. 2.2 Lack of Pre-planning None of the vessel's navigation officers was familiar with the concept of BRM, and there had been no pre-planning of the vessel's entry into the harbour. Even when the services of a pilot are anticipated, pre-planning of the inward passage tends to focus the navigator's attention on the complexities of the passage, and facilitates monitoring of the vessel's progress. The master did not monitor the vessel's progress adequately, and the OOW did not take the responsibility of advising the master of the danger of overrunning the alter-course position. Without the back-up, monitoring and support of the entire bridge team, the chances of a successful operation are reduced. 2.3 Reliance on Pilot The master confidently handed over the conduct of the vessel to the person who boarded at the pilot station. It was only when the vessel grounded that he realized he was not receiving the services of an experienced pilot. Before the chaotic situation that developed prior to the grounding, there were subtle clues that could have raised questions in the mind of the master as to the competence, if not the qualifications, of the pilot. There was the unprofessional response to his request for the pilot boat's position, and the pilot's first-name-only reply when he was asked for his name. However, any doubts created by the former would have been allayed to some extent when the master heard the MCTS Centre using the terms pilot and pilot boat during that morning's radio communications. In the event, the possibility of the master preventing the grounding was significantly reduced when he did not adequately monitor the vessel's progress. Being aware of the speed of the vessel in relation to the upcoming alter-course position (and the required 100 change of heading), would have put the master in a position to assume the conduct of the vessel when it was apparent that the pilot was not taking the appropriate action. 3.0 Conclusions 3.1 Findings Although pilotage is not compulsory in Gasp harbour, the master was advised that a pilot would board the vessel upon arrival at the approaches to the port. The vessel's agents did not advise the master that they had not secured the services of an experienced pilot. The master was in radio communication with a vessel that was apparently the pilot boat, through the Marine Communications and Traffic Services (MCTS) Centre. The person who boarded at the pilot station did not advise the master that he was not a pilot. The master handed over the conduct of the vessel in a manner that did not require the other person to contribute to an exchange of information. The master believed that the person who had boarded was a pilot, and so he relied on this person to conduct the vessel to the berth. There was no pre-planning of the passage nor Bridge Resource Management (BRM) for the harbour transit. With no BRM, there was no support from the officer of the watch (OOW) at a critical course-alteration point. The progress of the vessel was not adequately monitored. The vessel was moving at an excessive speed in an area unfamiliar to the master. The master did not assume the conduct of the vessel when he realized that no course alteration had been ordered. 3.2 Causes The YPAPADI grounded because a misunderstanding over who had conduct of the vessel led to a critical course alteration not being made. The master thought he had delegated the conduct of the vessel to the representative of the sub-agent, who had boarded at the pilot station and whom he had reason to believe was a competent pilot. This person did not make it clear that he was not a competent pilot. Contributing factors were: the vessel's agents did not advise the master they had not secured the services of a pilot, the conduct of the vessel was handed over in an informal manner, neither the master nor the officer of the watch closely monitored the vessel's progress, and the master did not take over the conduct when the critical course alteration was not executed. 4.0 Safety Action 4.1 Action Taken 4.1.1 Non-compulsory Pilotage As a result of this investigation, a TSB Marine Safety Advisory No.07/98 was forwarded apprising Transport Canada that the present pilotage system does not ensure that only qualified and competent mariners are used for pilotage services in non-compulsory ports.